Obstetrics Early Pregnancy: N&V, Hyperemesis Gravidarum, Ectopic Pregnancy, Miscarriage, Molar Pregnancy & Abortion Flashcards
In a uterine pregnancy, how will the hCG change?
How does this differ for an ectopic or miscarriage?
Will DOUBLE every 48 hours
This will NOT be the case in an ectopic or a miscarriage
If there is a rise of >63% hCG after 48 hours, what does this indicate?
Likely to indicate intrauterine pregnancy
If there is a rise of <63% hCG after 48 hours, what does this indicate?
May indicate ectopic pregnancy
If there is a fall of >50% hCG, what is this likely to indicate?
Miscarriage
What is an ectopic pregnancy?
When a pregnancy is implanted outside the uterus.
Where is the most common site of ectopic pregnancy?
Fallopian tube
Risk factors for ectopic pregnancy?
- Previous ectopic
- Previous PID
- Previous surgery to fallopian tubes
- Intrauterine devices (coils)
- Older age
- Smoking
What type of contraception can increase risk of ectopic pregnancy?
Intrauterine devices (coils)
When do ectopic pregnancies typically present?
6-8 weeks gestation
What should you always ask about in women presenting with lower abdominal pain?
- Possibility of pregnancy
- Missed periods
- Recent unprotected sex
Classic features of ectopic pregnancy?
- Missed period
- Constant lower abdo pain in L or R iliac fossa
- Vaginal bleeding
- Lower abdominal or pelvic tenderness
- Cervical motion tenderness (pain when moving the cervix during a bimanual examination)
It is also worth asking about:
- Dizziness or syncope (blood loss)
- Shoulder tip pain (peritonitis)
What gynaecological problem can shoulder tip pain indicate?
Ectopic pregnancy
What causes shoulder tip pain in an ectopic
The fallopian tube can rupture. Internal blood can collect under the diaphragm, leading to nerve irritation
1st line investigation in all women with abdominal or pelvic pain?
Pregnancy test
1st line imaging investigation in potential ectopic?
Transvaginal US
What may be seen on an US in an ectopic?
- Gestational sac containing a yolk sac or foetal pole may be seen in a fallopian tube
- Sometimes non-specific mass may be seen
- Mass containing an empty gestational sac –> blob sign, bagel sign, or tubal ring sign (all referring to same appearance)
- Mass representing a tubal ectopic pregnancy moves separately to the ovary –> Mass may look similar to a corpus luteum BUT this would move with the ovary
- Other features that may indicate ectopic:
- Empty uterus
- Fluid in uterus (may be mistaken as gestational sac) –> pseudogestational sac
Management of ectopic?
Termination
Termination options in ectopic?
1) Expectant –> awaiting natural termination
2) Medical –> methotrexate
3) Surgical –> salpingectomy or salpingotomy
What drug is used to terminate ectopic pregnancies?
Methotrexate
Following treatment with methotrexate, how long should you not get pregnant for?
3 months (teratogenic)
What is the criteria for EXPECTANT management of an ectopic (i.e. instead of surgery)?
1) Ectopic needs to be UNRUPTURED
2) Adenexal mass <35mm
3) No visible heartbeat
4) No significant pain
5) HCG level <1500 IU/l
Able to return for followup
Women with expectant management need careful follow up with close monitoring of hCG levels, and quick and easy access to services if their condition changes.
Criteria for METHOTREXATE management of an ectopic (i.e. instead of surgery)?
1) Ectopic needs to be UNRUPTURED
2) Adenexal mass <35mm
3) No visible heartbeat
4) No significant pain
5) HCG level <5000 IU/l
6) Confirmed absence of intrauterine pregnancy on US
Able to return for follow up
How is methotrexate given for an ectopic?
As an IM injection into a buttock
How does methotrexate work in an ectopic?
Methotrexate is highly teratogenic - halts the pregnancy and results in spontaneous termination
Common side effects of methotrexate?
Vaginal bleeding
Nausea and vomiting
Abdominal pain
Stomatitis (inflammation of the mouth)
Anyone that does not meet the criteria for expectant or medical management for an ectopic requires what?
Surgery
Criteria for surgical management of an ectopic?
- Pain
- Adenexal mass >35mm
- Visible heartbeat
- hCG levels >5000 IU/l
What type of management is required in ectopics with a visible heartbeat?
Surgery
What are the two options for surgical management of ectopic pregnancy?
1) Laparoscopic salpingectomy
2) Laparoscopic salpingotomy
Sapingectomy vs salpingotomy?
Salpingectomy –> involves a general anaesthetic and key-hole surgery with removal of the affected fallopian tube, along with the ectopic pregnancy inside the tube.
Salpingotomy –> A cut is made in the fallopian tube, the ectopic pregnancy is removed, and the tube is closed (i.e. tube is not removed)
What is the 1st line surgical management for an ectopic?
Laparoscopic salpingectomy
When would a salpingotomy be used instead of a salpingectomy?
May be used in women at increased risk of infertility due to damage to the other tube –> aim is to avoid removing the affected fallopian tube to increase chances of future fertility
Disadvantages of a salpingotomy over a salpingectomy?
There is an increased risk of failure to remove the ectopic pregnancy with salpingotomy compared with salpingectomy.
NICE state up to 1 in 5 women having salpingotomy may need further treatment with methotrexate or salpingectomy.
What further treatment may women treated with a salpingotomy for an ectopic require?
May need further treatment with methotrexate or salpingectomy.
What is given to rhesus negative women having surgical management of ectopic pregnancy?
Anti-rhesus D prophylaxis
What is a pregnancy of unknown location (PUL)?
A pregnancy of unknown location (PUL) is when the woman has a positive pregnancy test and there is no evidence of pregnancy on the ultrasound scan.
What produces hCG in an intrauterine pregnancy?
The developing syncytiotrophoblast of the pregnancy
If an ectopic pregnancy is not diagnosed and treated promptly, what complications can happen?
1) Fallopian tube or uterine rupture
2) Secondary massive haemorrhage
3) Death
An ectopic can be life-threatening.
Complications of surgical management of an ectopic?
Bleeding
Infection
Damage to local structures (uterus, bladder, bowel, vasculature)
What else should be offered to women having an ectopic?
Psychological support - represents the loss of what may be a much-longed-for pregnancy.
For women who have undergone a salpingectomy, there may be further emotional support needed to allow them to come to terms with the potential impact on their future fertility.
What is a miscarriage?
Spontaneous termination of an intrauterine pregnancy before 24 weeks gestation.
When does an EARLY miscarriage occur?
Before 12 weeks gestation
When does a LATE miscarriage occur?
Between 12-24 weeks gestation.
Define a missed miscarriage
Foetus is no longer alive but no symptoms have occurred
i.e. when a baby has died in the womb, but the mother hasn’t had any symptoms, such as bleeding or pain
Define a threatened miscarriage
Vaginal bleeding with a closed cervix and a foetus that is alive.
I.e. there is vaginal bleeding during pregnancy but this does not always mean that you will go on to have a miscarriage (83% chance of your pregnancy continuing)
What is an inevitable miscarriage?
Vaginal bleeding with an open cervix.
A diagnosed non-viable pregnancy in which bleeding has begun and the cervical os is open, but pregnancy tissue remains in the uterus. The pregnancy will proceed to incomplete or complete miscarriage.
What is an incomplete miscarriage?
Retained products of conception remain in uterus after miscarriage
What is a complete miscarriage?
Full miscarriage has occurred and NO products of conception left in uterus
What is an anembryonic pregnancy?
Gestational sac is present but contains no embryo.
A fertilized egg implants and a gestational (embryonic) sac forms and grows, but the embryo fails to develop.
What is the most common cause of miscarriage?
Anembryonic pregnancy (i.e. blighted ovum)
1st line investigation in potential miscarriage?
Transvaginal US
What are 3 key features in early pregnancy that appear sequentially on a transvaginal US (i.e. as each appears, the previous becomes less relevant in assessing viability of pregnancy)?
1) Mean gestational sac diameter
2) Foetal pole and crown-rump length
3) Foetal heartbeat
What are the 2 major risk factors for a miscarriage?
1) Increasing maternal age
2) Number of previous miscarriages
When are most miscarriages diagnosed?
<13 weeks (risk of miscarriage decreasing as gestational age increases)
What is the most common cause of miscarriage in the 1st trimester?
Chromosomal abnormality –> most common is autosomal trisomy (e.g. trisomy 16)
What is the most common single chromosomal abnormality causing miscarriage?
45X karyotype
Define aneuploidy
Aneuploidy is the presence of an abnormal number of chromosomes in a cell, for example a human cell having 45 or 47 chromosomes instead of the usual 46.
Why is increasing maternal age associated with increasing risk of miscarriage?
Maternal age is related to aneuploidy risk
What is miscarriage in the 2nd trimester typically due to?
1) An incompetent cervix (e.g. due to previous cervical surgery)
2) Or systemic maternal illness.
Typical symptoms of miscarriage?
1) Vaginal bleeding
2) Cramping abdominal pain
3) Passage of any fetal tissue or clots
Important areas to cover in history in potential miscarriage?
1) Symptoms of, and risk factors for, ectopic pregnancy
2) Menstrual history: last menstrual period (LMP), cycle length, days bleeding, severity & nature of bleeding
3) Pregnancy history (if known): dating based on LMP/ultrasound results
4) Past obstetric history: outcomes from previous pregnancies and complications
5) Past gynaecological history: cervical/uterine surgery, sexual history
Social history: smoking, alcohol, illicit drug use
Symptoms of an ectopic pregnancy?
- Unilateral abdominal pain
- Nausea & vomiting
- Pre-syncope or syncope
- Back pain
- Shoulder tip pain
- Rectal pressure or pain
Risk factors for an ectopic?
- Previous ectopic pregnancy
- Previous pelvic inflammatory disease
- Intrauterine contraception
- Previous tubal surgery including sterilisation
- Fertility treatment
What examination should be performed in potential miscarriage?
1) A thorough ABDO examination to assess for signs of an acute abdomen (e.g. rebound tenderness and guarding), which may be suggestive of an ectopic pregnancy.
2) Speculum examination
3) Vital signs recorded using an obstetric or maternal early warning chart.
4) Bimanual exam - if ectopic suspected
What abdo exam signs may be suggestive of an ectopic?
Rebound tenderness and guarding
Purpose of speculum exam in potential miscarriage?
1) assess the cervical os
2) rule out other sources of bleeding (e.g. cervical/vaginal pathology)
3) quantify the bleeding and assess for visible products of conception